Risk Adjustment Coding Gets a Technological Assist

Scott Mace, December 29, 2015

How a California physician practice designed a system to catch coder errors without burdening doctors.

Technology continues its climb toward what we would consider intelligence. Your average electronic health record is fairly stupid, being able to sort things in rows and columns, and find character strings. Analytics software adds more sophisticated algorithms that can stratify patients by comparing their symptoms to known risks for developing more serious adverse events.

Jennifer Pereur

In the nearly three years since I wrote about IBM's Watson and its attempt to move health IT into an era of what has become known as cognitive computing, I have seen scattered attempts to further explore its possibilities. Some concepts, such as rules-based engines, expert systems, heuristic algorithms, and other machine learning, have been around in one form or another since the 1970s. More recently, technologists have incorporated these components into the broader knowledge representation systems that cognitive computing encompasses.

I recently spoke with an independent practice association in northern California that seems to be pushing cognitive computing into an area I had not heard about before, this time not strictly to explore clinical research goals, but to achieve real benefits to the group's bottom line.

Jennifer Pereur is director of government programs at San Ramon, California–based Hill Physicians Medical Group, a provider network of more than 3,800 primary care physicians, specialists, sub-specialists, and consultants that manages 300,000 patients lives at risk under contract to Medicare Advantage, managed Medi-Cal, and commercial payers, as well as "some PPO work as well," Pereur says.

The Medicare Advantage dollars that CMS pays the group are risk adjusted, Pereur says. "If somebody has a lot of conditions, they get a higher risk score and, therefore, there is more money to take care of them and provide care for them," she says. "If it's a healthier member, then there are fewer premium dollars."

Therefore, Hill Physicians employs many different mechanisms to make sure it is getting accurate data on the health status of its patients. "Not only does it help us with accurate premiums, but it also helps us to identify members who might be good candidates for different disease management programs," Pereur says.